Citation Nr: 1335689 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 08-37 791 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to an initial evaluation in excess of 10 percent for degenerative arthritis of the right (major) shoulder (formerly diagnosed as residuals of right shoulder strain). REPRESENTATION Appellant represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD Bernard T. DoMinh, Counsel INTRODUCTION The Veteran served on active duty from January 1986 to December 1989. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2006 rating decision by the Atlanta, Georgia, Regional Office (RO) of the Department of Veterans Affairs (VA), which granted the Veteran service connection and a 10 percent evaluation for residuals of right (major) shoulder strain, effective November 29, 2002 (i.e., the date on which her original claim for VA compensation for a right shoulder disability was received by VA). The Veteran appeals the initial evaluation assigned for this orthopedic disability. Consideration must therefore be given regarding whether the case warrants the assignment of separate ratings for separate periods of time, from November 29, 2002, to the present, based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). In a July 2011 appellate decision, the Board, inter alia, denied the appeal for an initial evaluation in excess of 10 percent for residuals of right shoulder strain. The Veteran appealed this determination to the United States Court of Appeals for Veterans Claims (Court). In August 2012, the Court a joint motion of the appellant and the Secretary of VA to vacate the adverse July 2011 Board decision and remand the matter to the Board for further adjudication consistent with the Court's order. Once again, this appeal is now before the Board. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. FINDINGS OF FACT 1. The Veteran's service-connected right shoulder disability affects her dominant (major) upper extremity. 2. Prior to March 14, 2011, the Veteran's service-connected right shoulder disability was diagnosed as residuals of right shoulder strain, and was manifested by subjective complaints of pain, pain on use, and pain on motion, with limitation of motion on the extremes of flexion and only half of normal external rotation and slightly more than half of normal abduction due to pain (with fatigue, weakness, lack of endurance, but no incoordination or additional limitation of motion objectively demonstrated following repetitive use), which produces disability analogous to no more than moderate impairment of function of Muscle Group I. 3. From March 14, 2011, the Veteran's service-connected right shoulder disability is diagnosed as degenerative arthritis of the right shoulder and is manifested by radiographic evidence of arthritic changes of the right shoulder with subjective complaints of pain, pain on use, and pain on motion, with limitation of motion on flexion to no more than only shoulder level, no more than approximately 4/5ths of normal abduction, and no more than approximately 2/3rds of normal external and internal rotation due to pain (with stiffness, weakness, and tenderness on active movement but no additional limitation of motion objectively demonstrated following repetitive use). CONCLUSIONS OF LAW 1. Prior to March 14, 2011, the criteria for an initial evaluation above 10 percent for residuals of right (major) shoulder strain have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.71a, 4.73, Diagnostic Codes 5201, 5301 (2013). 2. From March 14, 2011, the criteria for a 20 percent evaluation, and no higher, for degenerative arthritis of the right (major) shoulder strain have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.71a, 4.73, Diagnostic Codes 5201, 5301 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) and VA's duty to assist. VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant and her representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. The current appeal for an initial evaluation above 10 percent for a chronic disability of the right shoulder is a downstream issue from a September 2006 rating decision, which initially established service connection for this orthopedic disability and assigned the initial rating being contested and its effective date (i.e., November 29, 2002). The Court held in Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91 (2006), that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. See also Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008). Thusly, to the extent that there is any defect in, or non-compliance with the statutorily prescribed VCAA notice requirements with respect to the claim for a higher initial evaluation for the right shoulder disability now at issue, these deficits are deemed to be non-prejudicial to the claim. VA also has a duty to assist the Veteran in obtaining evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the Veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence with regard to the increased initial rating claim adjudicated herein. As the claim stems from November 29, 2002, when the Veteran filed her original claim for service connection for the right shoulder disability at issue, the relevant time period and evidence that must be addressed in the adjudication of the claim encompasses the period from the date of claim to the present, in order to allow the Board to consider the applicability of a staged rating. See 38 C.F.R. § 3.400 (2013); Fenderson v. West, 12 Vet. App. 119 (1999). VA clinical records for the period spanning 2002 to 2011, including reports of VA orthopedic examinations dated in July 2003, July 2007 and March 2011, have been obtained and associated with the claims file, or are otherwise viewable on the VBMS and Virtual VA electronic information databases. The Board has reviewed the aforementioned VA examination reports and notes that the Veteran's pertinent clinical history was considered by the clinicians who performed them, and that these examiners provided adequate discussion of their clinical observations and rationales to support their individual findings and conclusions within the context of the Veteran's relevant history. The examinations are therefore deemed adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board notes that the Veteran's latest examination of her right shoulder is now over two and a half years old. The mere passage of time since that examination is not reason enough, alone, to require reexamination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007). Here, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's right shoulder disability since the most recent examinations. The Veteran has not argued the contrary. Based on the foregoing, the Board finds that the VA fulfilled its VCAA duties to notify and to assist the Veteran in the evidentiary development of the claim decided herein, and thus no additional assistance or notification is required. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board will therefore proceed with the adjudication of this appeal. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased ratings - generally. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2013). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2 (2013); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). If the disability more closely approximates the criteria for the higher of two ratings, the higher rating will be assigned; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7 (2013). It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2013). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). Based on the November 29, 2002 date of VA's receipt of the Veteran's original claim for VA compensation for a right shoulder disability, the relevant temporal focus for the claim for a higher initial rating is from November 29, 2002. See 38 C.F.R. § 3.400 (2013). The Veteran's service medical records show that she is right-hand dominant and that in 1987 she sustained a straining injury to the trapezius muscle of her right shoulder while moving heavy furniture during active duty. Subsequently, she was treated during service on several occasions for recurrent right shoulder and trapezius muscle strain with pain. She was awarded service connection and a 10 percent initial evaluation for residuals of right shoulder strain in a September 2006 rating decision. She appeals the initial 10 percent evaluation assigned. The Veteran's right shoulder strain may be rated as analogous to impairment due to limitation of motion of the major arm under 38 C.F.R. § 4.71a, Diagnostic Code 5201 (2013); alternatively, although no history of penetrative missile injury is shown, the right shoulder strain may also be rated as analogous to injury of Muscle Group I under 38 C.F.R. § 4.73, Diagnostic Code 5301 (2013), on the basis of impairment of the muscle group involving the extrinsic muscles of the shoulder girdle (i.e., trapezius, levator scapulae, and serratus magnus), whose function involves the upward rotation of the scapula and the elevation of the arm above the shoulder level. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). 38 C.F.R. § 4.71a, Diagnostic Code 5201 provides for the assignment of a 20 percent evaluation for limitation of motion of the major arm to only as high shoulder level. A 30 percent evaluation is assigned for limitation of motion of the major arm to only midway between the side and shoulder level. A 40 percent evaluation is assigned for limitation of motion of the major arm to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5003 also allows for the assignment of a 10 percent evaluation for arthritis established by X-ray affecting a major joint (such as the shoulder) even when the evidence does not show limitation of motion to a compensable level. 38 C.F.R. § 4.73, Diagnostic Code 5301 provides for the assignment of a noncompensable evaluation for slight impairment of function of Muscle Group I affecting the major upper extremity. Assignment of a 10 percent evaluation is warranted for moderate impairment of function of Muscle Group I affecting the major upper extremity. Assignment of a 30 percent evaluation is warranted for moderately severe impairment of function of Muscle Group I affecting the major upper extremity. Assignment of a 40 percent evaluation is warranted for severe impairment of function of Muscle Group I affecting the major upper extremity. As stated in the August 2012 joint motion of the appellant and the VA Secretary (and the implementing decision of the Court, which granted this joint motion), the Board must provide a thorough statement of its reasons and bases as to why it chooses to apply one of these Diagnostic Codes over the other to rate the Veteran's service-connected right shoulder disability. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992); Suttman v. Brown, 5 Vet. App. 127, 132-33 (1993). The assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Words such as "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2013). Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6 (2013). It is possible for a Veteran to have separate and distinct manifestations from the same injury that would permit rating under several Diagnostic Codes; however, the critical element in permitting the assignment of several ratings under various Diagnostic Codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). See also 38 C.F.R. § 4.14 (precluding the assignment of separate ratings for the same manifestations of a disability under different diagnoses). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45 (2013). VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) did not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare- ups. The guidance provided under DeLuca must be followed in adjudicating claims where a rating under the diagnostic code provisions governing limitation of motion should be considered. However, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 should only be considered in conjunction with the Diagnostic Code provisions predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). (a.) Factual background and analysis: entitlement to an initial evaluation in excess of 10 percent for residuals of right (major) shoulder strain prior to March 14, 2011. The Veteran underwent a VA examination to assess her right shoulder disability in July 2003. The examiner noted that the Veteran suffered an in-service right shoulder strain and that her condition existed since 1987. The Veteran described her symptoms as a piercing, stabbing pain in her right shoulder that radiated to her arm during activities, with a continuous ache at rest. She stated that her symptoms were constant and that a physician recommended bed rest for her condition as often as three times per year, for periods of three to five days. The Veteran reported that she treated her symptoms with bed rest and pain medication. She also indicated that she experienced a loss of strength, weakness, easy fatigability, and pain in her right trapezius muscle. In addition to these symptoms, the Veteran stated that when she used her arms for a period of time, her right shoulder ached; this occurred on a daily basis. Essentially, she reported that she was unable to use her right shoulder for prolong periods and that she could not keep up with her normal work requirements because her disability only permitted her to work for 3 to 3 1/2 hours at time before her symptoms flared up. On the physical examination, the examiner noted that the Veteran's disability involved Muscle Group I. There were no muscle wounds present. Palpation of the muscle revealed no loss of deep fascia or muscle substance and no impairment in muscle tone. There were no signs of lowered endurance or impaired coordination. Strength for Muscle Group I was graded at 5. The examiner noted that the muscle injury did not affect the particular body part function it controlled. There was no herniation and the muscle injury did not involve any tendon, bone, joint, or nerve damage. The examination also revealed that the Veteran's right shoulder joint was normal in appearance. The range of motion of her right shoulder was reported as follows: flexion to 180 degrees, with pain at 180 degrees; abduction to 180 degrees, with pain at 180 degrees; external rotation to 90 degrees, with pain at 90 degrees; and internal rotation to 90 degrees, with pain at 90 degrees. Range of motion of the right shoulder was additionally limited by pain and pain had the major functional impact. The right shoulder range of motion was not additionally limited by fatigue, weakness, lack of endurance, or coordination. The neurological examination revealed that peripheral nerves and sensory function were within normal limits. The right upper extremity reflexes revealed biceps jerk of 2+ and triceps jerk of 2+. The associated X-ray of the right shoulder was within normal limits. Following the examination, the Veteran was diagnosed with a right shoulder strain; subjective and objective factors associated with this diagnosis were both noted to include painful shoulder range of motion. The Veteran underwent a second VA examination to assess her right shoulder disability in July 2007. During the examination, she reported her right shoulder symptoms to include weakness, stiffness, giving way, lack of endurance, and fatigability. She denied experiencing swelling, heat, redness, locking, or dislocation of the joint. An additional symptom was reported as pain, pain which the Veteran described as burning and aching in nature. She stated that her pain occurred multiple times per day and that it traveled to her lower back. Her pain was elicited by physical activity and stress and it was relieved by medication. She stated that her disability limited her ability to perform tasks and that her arm fatigued easily. On the physical examination, the Veteran was noted to be right-hand dominant. Tenderness was noted in the right shoulder, but there was no evidence of edema, weakness, redness, heat, abnormal movement, guarding of movement, or subluxation. Range of motion of the right shoulder was reported as follows: flexion to 170 degrees, with pain at 170 degrees; abduction to 100 degrees, with pain at 100 degrees; external rotation to 45 degrees, with pain at 45 degrees; and internal rotation to 90 degrees, with pain at 90 degrees. The range of motion of the right shoulder was additionally limited following repetitive use due to pain, fatigue, lack of endurance. Findings from the associated X-ray examination of the right shoulder were within normal limits. The diagnosis of right shoulder strain was continued. Subjective symptoms were described as pain, weakness, and stiffness; objective findings were reported as tenderness and limited range of motion. The Board has considered the foregoing evidence and finds that because the clinical evidence prior to March 14, 2011 does not demonstrate compensable limitation of motion of the right (dominant) arm on objective testing under the criteria of 38 C.F.R. § 4.71a, Diagnostic Code 5201, and because it does not also objectively establish the presence of arthritic changes of the right shoulder on X-ray examination, there is no basis to assign even a minimum 10 percent evaluation under Diagnostic Codes 5003 or 5201. Alternatively, 38 C.F.R. § 4.73, Diagnostic Code 5301 permits the assignment of a 10 percent evaluation on the basis of moderate impairment of Muscle Group I. In this regard, the clinical evidence dated prior to March 14, 2011 demonstrates that the Veteran's service-connected residuals of right shoulder strain were manifested by subjective complaints of pain, pain on use, and pain on motion, with limitation of motion on the extremes of flexion and only half of normal external rotation and slightly more than half of normal abduction due to pain (with fatigue, weakness, lack of endurance, but no incoordination or additional limitation of motion objectively demonstrated following repetitive use). The Board finds that the degree of disability associated with this constellation of symptoms is analogous to, and more closely approximates the criteria of moderate impairment of function of Muscle Group I, such that the 10 percent evaluation presently assigned to the residuals of right shoulder strain adequately compensates her for the level of disability objectively demonstrated. The Board does not find, however, that the aforementioned symptoms more closely approximate moderately severe impairment of function of Muscle Group I so as to support the allowance of the next higher evaluation of 30 percent provided in Diagnostic Code 5301. See 38 C.F.R. § 4.7 (2013). In making this determination, the Board has considered the provisions of 38 C.F.R. §§ 4.40, 4.45 (2013) and DeLuca, 8 Vet. App. 202. VA has considered the Veteran's complaints and symptoms described, and finds, consistent with the detailed analysis above, that the 10 percent rating herein upheld encompasses the relevant symptoms. In view of the foregoing discussion, the Board finds that the greater benefit is afforded to the claimant through application of Diagnostic Code 5301 to rate her right shoulder disability as analogous to impairment of Muscle Group I, but that the facts of the case do not support the assignment of an initial evaluation greater than 10 percent for her residuals of right shoulder strain under this Diagnostic Code prior to March 14, 2011. Her claim for a higher initial evaluation for right shoulder strain in this regard must therefore be denied. Because the evidence in this case is not approximately balanced, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (b.) Factual background and analysis: entitlement to an evaluation in excess of 10 percent for degenerative arthritis of the right (major) shoulder (formerly diagnosed as residuals of right shoulder strain) since March 14, 2011. The Veteran's right shoulder disability was further assessed during a VA examination performed on March 14, 2011. She reported her symptoms as weakness, stiffness, giving way, lack of endurance, fatigability, tenderness, and pain. The Veteran denied experiencing swelling, heat, redness, locking, deformity, drainage, effusion, subluxation, or dislocation of her right shoulder. Flare-ups were reported to occur approximately four times per day and were precipitated by physical activity and stress. The Veteran stated that during periods of flare ups she experienced pain, weakness, and limited repetitious motion. Her symptoms were reportedly alleviated by bed rest, muscle rubs, and pain medication. In addition to these symptoms, the Veteran also reported having difficulty with standing and walking and an inability to sit for prolong periods due to a throbbing sensation in her shoulder and back. She also reported that her right shoulder became very weak after use and that she had difficulty performing tasks, such as driving, with her right hand and arm. The physical examination revealed that the Veteran is right-hand dominant. Weakness, tenderness, and guarding of movement were noted. However, there were no signs of edema, instability, abnormal movement, effusion, redness, heat, deformity, malalignment, drainage, or subluxation. There was no evidence of ankylosis. Range of motion of the right shoulder was reported as follows: flexion to 100 degrees, with pain at 90 degrees; abduction to 145 degrees, with pain at 145 degrees; and external and internal rotation to 65 degrees, with pain at 65 degrees. The right shoulder was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. An associated X-ray of the right shoulder revealed the presence of degenerative arthritic changes for the first time. Following the examination, the Veteran's diagnosis was changed to degenerative arthritis of the right shoulder. The examiner commented that this diagnosis was due to increased pressure and usage of the right shoulder overtime, which caused arthritic changes. Objective factors associated with this diagnosis were listed as decreased range of motion, stiffness, weakness, and tenderness with active movement. The Board has considered the foregoing evidence and finds that it generally demonstrates that, as of March 14, 2011, the Veteran's right shoulder disability is manifested by a first-time showing of radiographic evidence of arthritic changes of the right shoulder with subjective complaints of pain, pain on use, and pain on motion, with limitation of motion on flexion to no more than only shoulder level, no more than approximately 4/5ths of normal abduction, and no more than approximately 2/3rds of normal external and internal rotation due to pain (with stiffness, weakness, and tenderness on active movement but no additional limitation of motion objectively demonstrated following repetitive use). The onset of pain at 90 degrees of right shoulder flexion, for all practical purposes, limits her right (major) arm movement to no higher than the shoulder level, which supports the assignment of a 20 percent evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5201. Therefore, as this confers the greater benefit on the Veteran, the Board shall apply the criteria of Diagnostic Code 5201 to rate her right shoulder disability for the period from March 14, 2011. Any doubt in this regard is to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 4.3 (2013); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). However, as limitation of right arm motion to midway between the Veteran's side and shoulder is not clinically demonstrated, even factoring in any additional limitation of motion due to pain or fatigue, there is no basis to assign the next higher rating of 40 percent under Diagnostic Code 5201. Furthermore, as the constellation of symptoms discussed above do not more closely approximate moderately severe impairment of function of Muscle Group I affecting the major upper extremity, there is no basis to assign a 30 percent evaluation under 38 C.F.R. § 4.73, Diagnostic Code 5301. In making this determination, the Board has considered the provisions of 38 C.F.R. §§ 4.40, 4.45 (2013) and DeLuca, 8 Vet. App. 202. VA has considered the Veteran's complaints and symptoms described, and finds, consistent with the detailed analysis above, that the 20 percent rating herein assigned encompasses the relevant symptoms. Individual unemployability and extraschedular consideration. To the extent that a claim for individual unemployability based on the increased rating claim for degenerative arthritis of the right (major) shoulder (formerly diagnostically rated as residuals of a right shoulder strain) has been raised by the record, pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009), the Board notes that the clinical evidence does not objectively demonstrate or otherwise indicate that the Veteran is unable to secure and follow a substantially gainful occupation solely by reason of her service-connected right shoulder disability. As such, there is no basis to award individual unemployability under 38 C.F.R. § 4.16(a), or to refer her case to the Director of the Compensation and Pension Service for extraschedular consideration for individual unemployability, pursuant to 38 C.F.R. § 4.16(b) (2013). The Board further finds that there is no evidence of an exceptional or unusual disability picture associated with the Veteran's service-connected right shoulder disability. A rating in excess of the assigned schedular evaluations for the Veteran's service-connected disability addressed herein on the merits may be granted when it is demonstrated that the particular disability presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2013). To accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2013). The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2013) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. See Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. See Shipwash v. Brown, 8 Vet. App. 218, 277 (1995). Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board or the RO must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. The Board finds that there is no evidence that the Veteran's service-connected right shoulder disability has presented such an unusual or exceptional disability picture at any time between November 29, 2002 to the present, so as to require consideration of an extraschedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b) (2013). Specifically, the evidence of record does not indicate the Veteran is frequently hospitalized for this aforementioned service-connected disability and there is no indication that this orthopedic disability, by itself, imposes marked interference with her ability to work. The criteria of the applicable rating schedule are therefore deemed to adequately contemplate the Veteran's present level of impairment due to the right shoulder disability at issue, as individually considered. As such, the Board cannot concede that the Veteran's right shoulder disability, standing by itself, causes marked interference with her employment capacity. Higher ratings are available for this disability, but for the reasons described in the above decision, a higher rating was denied in this case. The clinical evidence fails to show that the disability picture created by the right shoulder disability, in isolation, is of an exceptional or unusual nature. Having reviewed the record with these mandates in mind, the Board finds that the schedular ratings presently assigned to this disability adequately reflect the state of its impairment for the periods to which they are applied, and that there is no evidentiary basis for referral of the case for extraschedular consideration with regard to this issue. ORDER An initial evaluation above 10 percent for residuals of right (major) shoulder strain prior to March 14, 2011, is denied. A 20 percent evaluation, and no higher, for degenerative arthritis of the right (major) shoulder strain from March 14, 2011, is granted. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs